Spokane County Fire District No. 12

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SPOKANE COUNTY FIRE DISTRICT NO. 12

 
 _____ Firefighter          _____ EMS


NAME:_______________________________________________________________________
ADDRESS:____________________________________________________________________
HOW LONG AT THIS ADDRESS:_______ TELEPHONE:__________________________
PERSONAL HISTORY
DATE OF BIRTH:_________ AGE:_____ MARITAL STATUS: ____SINGLE ____MARRIED
NAME OF SPOUSE:_____________________________________________________________
HEIGHT:_______  WEIGHT:_________  HAIR COLOR:___________  EYE COLOR:_______
SOCIAL SECURITY NUMBER:_______________________________
WASHINGTON STATE DRIVERS LICENSE #:______________________________________
RESTRICTIONS OR ENDORSEMENTS ON WSDL:__________________________________
TRAFFIC CITATIONS INLAST THREE YEARS:_____________________________________
FELONY CONVICTIONS:________________________________________________________
MEDICAL AND EMERGENCY:
IN CASE OF EMERGENCY NOTIFY:______________________________________________
RELATIONSHIP:______________________ ADDRESS/PHONE:________________________
PHYSICIAN:_____________________________________ PHONE:______________________
BLOOD TYPE:_______________ ALLERGIES:______________________________________
PHYSICAL RESTRICTIONS, DISABILITIES, OR LIMITATIONS (INCLUDE VISION, HEARING, BACK PROBLEMS, LIFTING ABILITY, FEAR OF HEIGHTS, ETC.)_____________________________________________________________________________

EDUCATION:
HIGH SCHOOL GRADUATE:  ___ YES  ___ NO ___ GED
COLLEGE (MARK HIGHEST YEAR COMPLETED): __0 __1 __2 __3 __4 __5 __6+
DEGREE __NONE __AA/AS __BA/BS __MASTER __OTHER (SPECIFY)________________
MAJOR AREAS OF STUDY______________________________________________________


EMPLOYMENT HISTORY:
PRESENT EMPLOYER:__________________________________________________________
ADDRESS:_________________________________________ PHONE:____________________
OCCUPATION:______________________________________ SHIFT:____________________
EMPLOYMENT DATE:_____________________________________
PREVIOUS EMPLOYER:________________________________________________________
ADDRESS:_________________________________________ PHONE____________________
OCCUPATION:____________________ EMPLOYMENT DATES:_______________________

FIREFIGHTER HISTORY:
Training:_____ None _____ Washington State Fundamentals of Firefighting
Other training (include dates, locations and certificates):_________________________________
______________________________________________________________________________
Experience: ____ None ____ Structural _____ Forest _____ Field _____other: list dates and locations:______________________________________________________________________
FIRST AID – EMS HISTORY:
Training:_____ None _____ Prior training – level:_____________ date expired:______________
 PRESENT QUALIFICATIONS:  _____basic first aid       _____advanced first aid
      _____first responder – expires:_____________
      _____ EMT – state:________ expires:________
      _____IV tech _____ Airway tech _____Defib
      _____Paramedic – state: _____ expires:_____
      _____RN  _____ LPN ____________ other

EXPERIENCE:_____ none _____ field EMS (fire or ambulance) _____ ER _____ other, give date and location ________________________________________________________________

REFERENCES: (no relatives) list name, address, telephone number
1.  ____________________________________________________________________________
2.  ____________________________________________________________________________
3.  ____________________________________________________________________________

CERTIFICATION:
I hereby certify that the answers given in this application are true and correct to the best of my knowledge. Signature____________________________________________ Date:____________
Acceptance by District: ___________ accepted  __________ not accepted
Fire Chief:_____________________________________________________ Date:___________

 

MEDICAL EXAMINATION QUESTIONEER

Are you in good health__________ do you have or previously had any disabilities whereby you full physical capacities are limited  yes:_____ no:_____ if so explain:______________________
______________________________________________________________________________

Have you ever had any of the following diseases or conditions: (if so please explain)
 Heart trouble:____________________________________________________________
 Kidney or Urinary trouble:__________________________________________________
 Tuberculosis or lung disease:________________________________________________
 Stomach ulcers/gastrointestinal disease:________________________________________
 Diabetes:________________________________________________________________
 Epilepsy:________________________________________________________________
 Mental disease:___________________________________________________________
 Nervous system problems:__________________________________________________
 Rheumatism/arthritis:______________________________________________________
 Back problems:___________________________________________________________
 Allergies (ie: asthma, hay fever, eczema):______________________________________
 Vision defects:___________________________________________________________
 Hearing defects:__________________________________________________________
 Hernias:________________________________________________________________

What serious illnesses, accidents, injuries or operations have you had?______________________
______________________________________________________________________________

List any government, insurance compensations or disability awards you have received.
What for?______________________________________________________________________
______________________________________________________________________________

(I hereby certify that the above answers are full, complete and true to the best of my knowledge.)

Volunteer’s signature:______________________________________ Date:_________________

 

 


SPOKANE COUNTY FIRE DISTRICT NO. 12

PHYSICAL EXAMINATION

APPOINTMENT TIME AND DATE:_______________________________________________
TO BE FILLED OUT BY PHYSICIAN:
HEIGHT:_________ WEIGHT:_________ PULSE:_________ BLOOD PRESSURE:_________
GENERAL APPEARANCE:_______________________________________________________
VISION:      UNCORRECTED: R_______ L_______         CORRECTED:  R_______ L_______
NECK:________________________________________________________________________
LUNGS:_______________________________________________________________________
HEART:_______________________________________________________________________
ABDOMEN:___________________________________________________________________
INGUINAL REGION:____________________________________________________________
SPINE:________________________________________________________________________
EXTREMITIES:  LIMITED MOTION OR IMPAIRED FUNCTION, DEFORMITIES:________
______________________________________________________________________________
NERVOUS SYSTEM:              PUPILS:____________   KNEE JERKS:_____________
                    ROMBERG____________   TREMORS______________   GAIT_____________

PHYSICIAN’S OPINION:
CAPABLE OF SUSTAINED ARDUOUS DUTY:_______________________________
CAPABLE OF MODIFIED DUTY:__________________________________________
LIMITATIONS:__________________________________________________________


_______________________________________  __________________
PHYSICIAN’S SIGNATURE                                            DATE


____________________________________________ 
VOLUNTEER’S SIGNATURE

  
____________________________________________ 
SIGNATURE OF FIRE CHIEF OR EMS DIRECTOR
 

 

 


SPOKANE COUNTY FIRE DISTRICT NO. 12
FIRE DISTRICT POLICY

REQUIREMENTS FOR PHYSICAL EXAM BY PHYSICIAN            DATE:_______________

If a physical examination is required, the Fire Chief and/or EMS Director will inform the District Secretary who will then fill in the Procedure form, make the appointment with the Medical Director at which time the volunteer will take the form back to either the Fire Chief or the Ambulance Director before said appointment and have it signed.  At the time of the appointment, the volunteer will have the Medical Director sign and return the form to the secretary.


      COMMISSIONERS:

      Gregg Wernz
      Ron Tee
      Tom Pottratz

 

 

 

 

 


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